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Infected ischaemic diabetic foot ulcer — MSRA MCQ

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HardAnkle and FootInfected ischaemic diabetic foot ulcerMSRA

A 73-year-old man with type 2 diabetes, established peripheral sensory neuropathy and known peripheral arterial disease presents with a 2-day history of a blister beneath the right first metatarsal head that has broken down. He is afebrile and feels otherwise well. Examination shows a 12 mm plantar ulcer with purulent discharge and erythema extending 1.2 cm beyond the ulcer margin. The forefoot is cool and mildly mottled. Capillary refill at the great toe is 5 seconds. Dorsalis pedis and posterior tibial pulses are absent by palpation and not detectable using a handheld Doppler. There is no crepitus, lymphangitis, rapidly spreading erythema or pain out of proportion. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Refer immediately to acute services and inform the multidisciplinary foot care service

Explanation lettering: C = shown as A · E = shown as B · D = shown as C · B = shown as D · A = shown as E

This is a limb-threatening diabetic foot problem. The ulcer has clinical features of infection: purulent discharge, erythema and local inflammatory change. More importantly, it is accompanied by limb ischaemia, indicated by a cool mottled forefoot, markedly delayed capillary refill and absent pedal arterial Doppler signals. NICE specifies ulceration with limb ischaemia as an indication for immediate referral to acute services, with notification of the multidisciplinary foot care service. Absence of fever or systemic inflammatory features does not reduce this urgency. A is inappropriate because outpatient oral treatment and review may delay revascularisation assessment and definitive infection management. B reflects the pathway for other active diabetic foot problems, but is insufficient where ulceration coexists with limb ischaemia. C may form part of subsequent hospital assessment, but outpatient vascular investigation should not delay acute escalation. D includes useful investigations in some diabetic foot infections, but sampling, radiography and community offloading do not address the immediate threat posed by infected ischaemic tissue. Acute services can coordinate urgent vascular, surgical, microbiological and multidisciplinary foot input.

Reference: NICE NG19: Diabetic foot problems: prevention and management — Recommendations, section 1.4 Referral (Published 2015; last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations NICE NG19: Diabetic foot problems: prevention and management — Terms used in this guideline (Published 2015; last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations